Female genital mutilation (FGM) is a form of violence against the girls and the women and also an infringement into the rights of the women in the society. It is practiced mostly in Africa, but migration has revolutionized its spread to almost all parts of the world. The government and the constituted authorities, our traditional rulers, the legislative, the judiciary, and the law enforcement agents have the machineries to stop this inhuman behavior, but they lack the will and the necessary information about the incidence and consequences of FGM. The review involved Internet and literature search mostly those written on the African continent and some that were specific to Nigeria from 1999 to 2018. This article reviewed the spread, the obstetrics and the gynecological complications, the roles of the traditional circumcisers, and the negative and the positive roles of the caregivers, especially its medicalization in the abandonment of FGM in Nigeria. The article also looked critically at the best ways to achieve zero tolerance to FGM. To achieve the targeted zero tolerance to FGM, the identified factors have to be tackled holistically.

Female genital mutilation/cutting (FGM/C) is defined as all the procedures which involve the partial or total removal of the external female genital organs for nontherapeutic reasons[1],[2]. Different classifications have been used for FGM/C by various authors, but the most acceptable or adopted is the WHO classification[1],[2],[3],[4]. This classification is based on the extent of mutilation/cutting carried out on the female external genitalia[1],[4]. Type 1 FGM/C involves the removal of the prepuce with or without partial or total removal of the clitoris. Type 2 FGM/C involves partial or total removal of the clitoris and parts or all of the labia minora. Type 3 FGM/C involves the removal of all the female external genitalia, leaving a small opening for menstrual and urine flow. However, type 4 FGM/C or the unclassified type involves all other forms not included in types 1–3. These include cutting, burning, piercing, scrapping, and cauterization[2],[3],[4],[5].

The prevalence of FGM varies in different parts of the world, and these ranges between 0.6% and 98%[6],[7],[8],[9]. FGM is practiced almost in all countries in the world. Migration of people from one country to the other has also altered the previously documented prevalence by various authors[10]. In Sudan, 96.6% of girls are mutilated before the age of 6 years[5]. In general, Africa, Middle East, and Asia have the highest prevalence globally[11]. Hotspots such as Egypt, Ethiopia, Tanzania, Somalia, Mali, Burkina Faso, Gambia, Guinea, Nigeria, sierra Leone, Iraq, Iran, Yemen, India, Malaysia, and Indonesia have been documented by various authors[5],[11].

More than 200 million girls and women have been mutilated all over the world. More than 20 million (10%) of these are from Nigeria[6],[7]. However, the prevalence varies form one geopolitical zone to the other. Some authors quoted the prevalence of 2.9% in the South-East, 20.7% in the North-West, 9.9% in the Northcentral, 25.8% in the South-South, 49.0% in the South East, and 47.5% in the South-West[6]. Some hotspots with very high prevalence were also documented in different geopolitical zones in Nigeria: Osun 76.6% (Southwest), Ebonyi 74% (South East), Ekiti State 72.3% (South-West), Imo State 68% (South-East), and Oyo State 65.6% (Southwest)[8].

The circumcisers are traditional practitioners, birth attendants, elderly women, and trained caregivers such as community health extension workers (CHEWs), nurses/midwives, and doctors[11]. The involvement of the trained caregivers (medicalization of FGM) is a dangerous dimension to the abandonment of FGM[12].

The age when FGM is carried out also varies from countries to countries. Generally, from neonatal period to the time just before delivery of the first baby[3],[4],[5],[12],[13]. Awusi reported that 71% of the cases of FGM were carried out at marriage among the Isoko tribes, South-South Nigeria[13].

The perpetrators gave many reasons to justify their involvement in this dehumanizing acts, which includes satisfying religion obligations in Christianity and Islamic injunction/teachings, prevention of early neonatal deaths during delivery by preventing the fetal head from touching the clitoris, the rights of passage from girl to womanhood, prevention of promiscuity, enhancement of the girls femininity by excision of the clitoris which make female more of a male, and hygiene and esthetic reasons, to make marriage an effortless process and to prevent recurrent genital infections[3],[4],[13],[14]. Others, are family honor and increasing sexual pleasure of the husband.

Complications from Female Genital Mutilation

The complications from this inhuman barbaric and unpopular practice in our society are devastating. The pains, agony, trauma, and the attendant risks to the life existence of the woman in this world after FGM are in three phases: the day of the mutilation, the day of the first sexual intercourse (possibly on the wedding day), and the day of deliveries. Many end in morbidities or mortalities while passing through these phases. The earlier complications include hemorrhage, damage to other structures, dislocation, and fracture of the limbs while restricting the girl movements during the procedure. The spread of infections such as urinary tract infections, HIV, hepatitis virus, tetanus and urinary retention are quite common in this group of girls and women[10]. The late complications include keloids formation, vulva and pelvic abscesses, recurrent urinary tract infections, fistulae formation (vesicovaginal and rectovaginal fistulae), infertility, primary postpartum hemorrhage, obstructed labor, dyspareunia, gynetresia, clitoridal cysts, depression, increase divorce rate, anorgasm, increase in surgical intervention in labor, and physical and mental torture[10],[14],[15],[16],[17],[18].

Female Genital Mutilation Abandonment in Nigeria: The Past and the Present

Although FGM was seen initially as religion and ancestral obligations for the existence of women races and reproductive continuity and sanctity, these beliefs have changed because of the awareness of the complications that result from this fruitless and inhuman venture. In view of this awareness, through health education, campaigns, and other several measures have been instituted towards the abandonment of FGM, but very little results have been achieved. Some of the measures instituted were the provision of alternative sources of income for the circumcisers, legislation, awareness campaigns, community leaders participation in the abandonment, education of the girls, and the efforts of the nongovernmental organizations and professional bodies[12],[18],[19],[20],[21],[22],[23]. The poor results achieved from all these instituted measures showed that these measures were not well implemented or are not the best approach to its abandonment.

The provision of alternative sources of income for the circumcisers, such as vocational trainings, in areas of hairdressing, fashion designing or tailoring, carpentry or furniture making and the distribution of equipment and soft loans or credit facilities to the graduands to jump-start these businesses[24],[25],[26]. In a statement form, the declaration for the abandonment of FGM by the Circumcision Descendants Association of Nigeria in Ibadan in May 2016 is the provision of the alternative sources of income to alleviate the possible economic effects on their members[22]. Unfortunately, this has not yielded the expected result of zero tolerance to FGM abandonment after several years of implementation.

Community leaders, the circumcisers, religions leaders, and opinion leaders in different parts of Nigeria were encouraged to openly declare the abandonment of FGM in their communities and religious centers. In Oyo state, Nigeria, this was done in 2017 with good media coverage. Communities such as Ekoinde, Ede, Iwo, and Apomu in Osun State, Nigeria, also declared openly their complete abandonment of FGM[22]. This will be a good approach since the community and religious leaders have firm control over their subjects.

Involvement of the men and the youths in the communities has also been used as a way of achieving zero tolerance to FGM abandonment. UNFPA introduced the participation of the “FGM champions.” These young and energetic vanguards are expected to educate the members of the communities of the complications associated with FGM, the legal implications and report any perpetrators to the appropriate authorities[26]. Lagos state, Southwest Nigeria, have a strong and vibrant youth team campaigning against FGM. They move from school to school to create awareness for FGM abandonment. This group was inaugurated and trained by UNFPA in November 2017.

Awareness campaign and education about the medical, social, and psychosexual complications involved in FGM, the abuse of the rights of the girls or the women and that FGM has no medical, sociocultural or religion benefit is a potent tool in the abandonment of FGM. Education gives the vulnerable group the power to take a firm decision for themselves or for their female children based on the information received and not relying on taboos or beliefs that will endanger their reproductive lives or that of their girl child or send them to early and untimely deaths[18],[26],[27]. Some good spirited individuals, nongovernmental organizations, and corporate bodies have sponsored radio and television programs and jingles in Oyo and Osun States, Nigeria, on the consequences of FGM and the importance of abandoning it[6].

The legislative or legal approach is a vital tool in the abandonment of FGM, to sanction the perpetrators and their accomplices. As at 2012, only about a quarter of the 36 states in Nigeria – Bayelsa, Cross River, Edo, Ekiti, Enugu, Imo, Ogun, Osun, Rivers, and Lagos – have criminalized FGM (reference). It was in May 2015, that federal. The Government of Nigeria passed a law criminalizing FGM/C in the violence against person prohibition act 2015[28]. Unfortunately, nobody has been charged to court or prosecuted for FGM/C since 2012 in Nigeria. The question is, are the laws/bills mere paperwork? Our culture does not support family members reporting themselves to the law enforcement agents or to sue a family member to court. A Yoruba adage says “friendship or relationship ends after a court case.” This makes reporting to the law enforcement agents or to institute legal actions against perpetrators difficult or impossible. FGM/C is carried out secretly, and only close family members will have fresh and detailed information about the act.

The activities of the government health institutions, nongovernmental agencies, and professional bodies such as the federal and the state ministries of health, the International Federation of Gynaecology and Obstetrics, the Society of Gynaecology and Obstetrics of Nigeria, the Nigerian Medical Association, the Medical and Dental Council of Nigeria, the National Association of Nigeria Nurses and Midwives, UNICEF, and UNFPA, have been on the increase in the last 15 years with initial encouraging results[3],[18],[26],[27]. However, the emergence of the dangerous dimension of “medicalization” of FGM/C has made it abandonment difficult. Some health-care professionals such as the doctors, nurses, and CHEWs continuously carry out FGM/C with the aim of preventing the associated compilations such as infections, injuries, pains, and excessive bleeding. They, however, did not take into the cognizance that the long-term complications still occur. This is an important area, where the different health regulatory bodies have to tackle aggressively to achieve our target of zero tolerance to FGM in Nigeria.

Although various measures instituted in achieving zero tolerance to FGM/C yielded unimpressive results, other measures are available to circumvent these hurdles to achieve excellent results.

The holistic harmonization of the previously instituted measures, but focusing more on; education and enlightening campaigns at the grass root levels, with nonsophisticated media (radio) in local dialects, simple enough for the nonelites understanding. Second, addressing medicalization of FGM/C with the aim of instituting appropriate sanctions against caregivers involved in FGM/C, by the concerned professional and health-care regulatory bodies. Medicalization of FGM is a serious issue, until tackled aggressively abandonment may be difficult or impossible. Third, invigorating the youth vanguards such as “FGM Champions,” FGM youth clubs in schools and villages and finally the incorporation of FGM/C into the educational curriculum from primary to tertiary educational levels.

When these four basic factors or measures are employed effectively, the other measures will be instituted with little or minimal efforts and yield impressive results.

Conclusion

FGM/C is a devastating health issue that strives under the pretext of social, cultural, and religious beliefs. It is a violation of the rights of the girls and women to life, to health care and protection, to be free from all forms of torture and discrimination and the right to gender equity and equality. Measures instituted toward its abandonment yielded very poor results. Unfortunately, medicalization has made it abandonment a mirage.

However, educating the populace on the associated complications, the rights of the girls and the women, and the incorporation of FGM into the school curriculum and addressing the issue of medicalization will not only make the other measures easier to implement, but enhance speedy achievement of zero tolerance to FGM/C.

Shell Duncan B, Carolyne N, Moore Z. The medicalization of female genital mutilation cutting: What do the data reveal? Evidence to end FGM/C. Research to help women thrive. New York: Population Council; February, 2017.